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Why are Kenya’s doctor’s on strike?

Photo by JC Gellidon on Unsplash.

The Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) recently called for an industrial action among its members, the majority of whom work in public healthcare facilities. Of the 19 issues raised, the two main concerns are the full implementation of the 2017–2021 collective bargaining agreement (CBA) and the posting and retention of medical interns. Doctors’ strikes worldwide are often bedeviled by two issues: the right of the worker (in this case, the doctor) to strike and the ethical dilemma it creates due to the absence of patient care during industrial action, which interferes with a person’s fundamental right to receive the highest attainable standard of healthcare.

Industrial actions in the health sector cause peacetime non-epidemics, such as cholera outbreaks, arising from failures in public healthcare systems. In addition, they deepen economic segregation in countries like Kenya, where the bulk of the population seeks care from publicly funded healthcare systems, creating barriers where only those who can afford private services are able to access healthcare. Ultimately, the direct impact of such industrial actions is hard to quantify, since they are multidimensional; the effects depend on the scope, duration, availability of essential lifesaving services, range of medical cases, and available care alternatives. With the foregoing, it is easy to see how healthcare providers who undertake industrial actions often grapple with pragmatic and moral dilemmas. 

In Africa, healthcare workers’ strikes have become more frequent, with common complaints concerning fair remuneration, safe working conditions (considering the COVID-19 pandemic, amid other challenges, for example), and skewed government policies that directly affect healthcare professionals (such as the posting of medical interns and their terms of service). There are also internal and external socioeconomic and political forces that strain human resources for health. These include the disparity between the optimal and actual doctor-to-patient population ratio, and the fact that most highly skilled medical professionals are localized in urban areas. This situation causes a surge in patients visiting advanced healthcare facilities in urban areas, which increases the workload among these highly skilled professionals and unintentionally waters down the quality of care they are able to offer. Government policies now advocate for task shifting of formerly specialized services to other cadres of healthcare workers (such as volunteer community health providers), who may not have an in-depth grounding in the health issues they would encounter. 

This is the fourth industrial action since the KMPDU was established as a trade union on August 30, 2011. The objective of the union was to champion the aspirations of doctors (medical doctors, pharmacists, and dentists), healthcare professionals, and Kenyan citizens to achieve healthcare as a human right. Additionally, the union aimed to advocate better working conditions for its members, better terms of service, and improved labor conditions for members and their employers. 

What necessitated the establishment of a doctors’ union in 2011 and not earlier? Prior to the enactment of Kenya’s new constitution in 2010, labor laws such as the Labour Relations Act of 2007 categorized the role of doctor as a managerial position and an essential service; therefore, doctors could not join labor unions or picket. This changed with the 2010 constitution, which made it possible for doctors to register a labor union that could address key issues impacting the practice of medicine in Kenya.  

After the first doctors’ strike in December 2011, the government set up the Musyimi Task Force on Strengthening Health Service Delivery. This task force had six union members and six government representatives. On top of creating a return-to-work formula, the committee drew up a collective bargaining agreement. The Musyimi report, dated January 25, 2012, highlighted key issues faced by doctors, such as inadequate health facilities and infrastructure, the erratic supply of pharmaceutical services and non-pharmaceuticals, the lack or malfunctioning of diagnostic equipment, inadequate staffing of healthcare workers, inadequate budgetary provisions for training of healthcare personnel and specialists, the need for compensation of registrars undertaking training in national teaching hospitals, attempts to lock doctors out of management in public health institutions, the underfunding of the health sector, and the need to strengthen performance management in the ministries, among other critical concerns.

One of the major reasons for the pervasiveness of doctors’ strikes in Kenya is devolution, during which the delivery of healthcare services was transferred from the national government to the counties, a process that was carried out in a hurried manner—over a six-month period—following the promulgation of the new constitution in 2013. This move was politically motivated, as “resources followed functions” and the newly elected governors needed more resources. This hurried transition did not consider the limited capacity of county governments to manage human resources for health and provide the required medical supplies.  

Devolution brought about a further delay of salary payments, prolonged stockouts of essential medical commodities and supplies (including medications and consumables), lack of clarity on career-progression management of healthcare workers, and other grave conditions. There were also cases of the discrimination of healthcare workers who were not considered natives of the counties they were posted to. These issues not only strengthened the doctors’ labor union but also increased their zeal for industrial action. Through their union, the doctors negotiated for a collective bargaining agreement in 2013 with the national government. The 2013 CBA addressed the terms of payment and working conditions of doctors, demanding salaries that aligned with the labor market, additional payment for any services offered beyond the stipulated 40-hour work week, a review of doctor’s job groups and promotion criteria, as well as the deployment and recruitment of doctors. However, this CBA was not implemented, since the government claimed that it was not registered by the industrial courts and the county governments, who were the new employers and had refused to take responsibility for it.

The 2017 strike, which lasted 100 days (between December 5, 2016, and March 14, 2017), demanded the fulfillment of the 2013 CBA. However, it was fraught with failed negotiations, power plays among both political and union leaders, mistrust, miscommunication, and political interference. At the end of it all, the union leaders were jailed for one month for contempt of court as they failed to obey a December 2016 court order compelling them to stop the industrial action. The union officials appealed the judgment and were later released before completing the one-month sentence.

The current, ongoing strike commenced on March 13, 2024, after the government, defying court orders, reneged on its earlier agreements to fully implement the 2017 CBA. Specifically, doctors are demanding payment of basic salaries as per the 2017 CBA and in compliance with the court order of October 28, 2021. They also demand comprehensive medical insurance for all doctors working in Kenya, the posting of medical officer’s interns, the hiring of doctors currently out of employment and those on contract, and the provision of medicines in all healthcare facilities, among other demands.

According to the head of the public service, Felix Koskei, the resolution of the strike falls within the concurrent mandate of both national and county governments. However, so far there has been no comprehensive government action taken toward concluding this strike and creating industrial harmony.

An external observer gets the impression that these strikes are recurrent and never comprehensively resolved. What is also evident is the evasive approach taken by both national and county levels of government, who try to delay and pass the buck to the next regime. As each new government comes into power, it evades responsibility for commitments made by previous leadership, arguing that such commitments should not be lorded over them. Yet the core issues at stake are the poor management of human resources for health as well as the lack of commitment to honor court directives, any return-to-work formula, or collective bargaining agreements.

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